TB News from India: September-October 2006

Health and Development Initiative-India, (www.healthinitiative.org), publishes 'TB News from India' once every two months. The objective of newsletter is to highlight issues related to Tuberculosis and HIV/AIDS control in India and enlist political, public, professional and administrative support for its cause. Health and Development Initiative-India is a not-for-profit organization and the news items have been quoted from various sources for fair use and in public interest. Reproduction of the material published is welcome provided a reference is made to the original source of the news item and TB News from India.

Editorial Note: It is XDR-TB now!

As if the sufferings inflicted on millions of human beings by tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB) were not enough, the TB epidemic has now arrived in it is more deadly form. WHO has sent out warning to national governments about existence of Extensive Drug Resistant TB (XDR-TB), a virtually untreatable form of white plague. Recent findings from a survey conducted by WHO and CDC on data from 2000-2004 found that XDR-TB has been identified in all regions of the world but is most frequent in the countries of the former Soviet Union and in Asia.
XDR-TB poses a grave public health threat, especially in populations with high rates of HIV and where there are few health care resources. The managers of Revised National Tuberculosis Control Programme in India need to take a serious note of this dangerous development. The country is yet to make a provision for nation wide availability of drugs to treat MDR-TB. The HIV-TB collaborative activities are in nascent stage in India. The emergence of yet another virulent form of TB may jeopardize the significant gains made by RNTCP.
As recommended by WHO Guidelines for the Programmatic Management of Drug Resistant Tuberculosis the country must continue to strengthen basic TB care to prevent the emergence of drug-resistance, establish collaboration between HIV and TB control programmes to provide necessary prevention and care to co-infected patients and make provision for laboratory infrastructures to enable better detection and management of resistant cases.

Drug-resistant strains of tuberculosis spark concern from WHO New York, Sep 5 2006:

The World Health Organization (WHO) has expressed concern about the emergence of virulent strains of tuberculosis (TB) that are virtually untreatable with existing drugs and called for the strengthening of prevention measures. Extensive Drug Resistant TB (XDR-TB) is resistant to not only the two main first-line TB drugs - isoniazid and rifampicin - but also to three or more of the six classes of second-line drugs.

Recent findings from a survey conducted by WHO and the US Centers for Disease Control and Prevention (CDC) found that XDR-TB has been identified in all regions of the world but is most frequent in the countries of the former Soviet Union and in Asia. "XDR-TB poses a grave public health threat, especially in populations with high rates of HIV and where there are few health care resources," said WHO in a statement issued in Geneva. Separate data on a recent outbreak of XDR-TB in an HIV-positive population in Kwazulu-Natal in South Africa found alarmingly high mortality rates, said WHO. 52 out of 53 patients identified with XDR-TB died within 25 days on average, including those benefiting from antiretroviral drugs.

WHO noted that its recommendations for managing drug-resistant strains of TB include strengthening basic TB care, ensuring prompt diagnosis and treatment of drug resistant cases, increasing collaboration between HIV and TB control programmes, and boosting investment in laboratory infrastructure.
For further details visit: http://www.who.int/mediacentre/news/notes/2006/np23/en/index.html

TB biggest killer of HIV Positive
Kounteya Sinha, Times News Network, 10 Aug, 2006

NEW DELHI: Tuberculosis has become the single largest killer of AIDS patients in India. Figures compiled by India's National AIDS Control Organization has revealed a catastrophic trend - over 60% of AIDS patients contract and ultimately die of TB. What's worse, AIDS is fuelling a resurgence of TB in the country. Faced with this double plague, India has now decided to scale up and integrate the National AIDS and TB control programmes from 2006. Under phase three of the National AIDS Control Programme (NACP) during the next five years, in which India plans to spend $2.5 billion, $500 million is being kept aside solely for treatment and care.

By 2012, India plans to set up 2500 Integrated Counselling and Testing Centers (ICTC) in universities, hospitals and medical centers across the country. At present, there are 2815 ICTC that check AIDS patients for TB. According to Dr Kurien Thomas from Christian Medical College, Vellore, who has designed the NACP III programme, the additional ICTCs will test 21 million people, of whom 3 million are expected to have symptoms of TB. These people will then be referred to India's Revised National TB Control Programme (RNTCP). Also, the present Voluntary Counselling and Testing Centers, that check patients for AIDS, will be integrated into ICTCs. NACP phase II was completed in March and the next phase would be implemented during the 11th five-year plan. The implementation is likely to start from November in 2006. "Of the 5.2 million HIV infected Indians, over 10% are expected to have full blown AIDS.

Every AIDS patient has 15% chance every year of developing TB, which shows that every AIDS patient will develop TB some time in their life. Under NACP III, we will confront both TB and AIDS together. When people become infected with TB and AIDS, it is almost always an irreversible formula," Thomas said. Read the full story at: http://timesofindia.indiatimes.com/articleshow/1879281.cms

Status of TB Control in Uttar Pradesh
HIV cases converting into TB at alarming rate
Times News Network, 30 Jul, 2006 Lucknow:

The Human Immunodeficiency Virus (HIV) cases in Uttar Pradesh, the most populous state of country, are now getting precipitated in the form of tuberculosis (TB). Their conversion rate is extremely high, according to experts of World Health Organization (WHO) working in different cities of the state.
Officials with the state TB cell estimate that at present one TB patient has the potential to infect 15 others, all because of the decline in immunity levels.

According to state TB officer (STO) BK Agarwal, country's northern zone, comprising UP, has been marked as a high alert zone. Data available with the WHO consultants clearly mentions that there are nearly 230,000 cases of TB in the state. This is despite the fact that all 70 districts of the state have been covered under the Directly Observed Treatment- Short course (DOTS).

The DOTS programme was launched way back in 1995. Officials, however, claimed that at present more than 500,000 patients have been put on DOTS therapy through 14,059 centers operating in various parts of the state. The earlier national tuberculosis programme (NTP), it is learnt, had been declared as a failure by the government itself. It was found that the programme met only 30 per cent of the expected results. It has now been replaced by the Revised National Tuberculosis Control Programme (RNTCP). But the revised programme, officials admit, is yet to reach every nook and corner of the state.

The diagnostic part of the disease is one of the most critical areas which have to be taken into account. There are instances wherein the doctors of various primary health centers (PHCs) have not been able to diagnose the disease properly. As a result they were not able to avail the DOTS therapy in time," said a senior officer with the UP TB cell on condition of anonymity. Another constraint is low density of DOTS centres. Sources said that the department is now seeking help of NGOs and Integrated Child Development Services Programme by equipping them with proper training so that they can help in propagating the therapy in villages.
Full story at: http://timesofindia.indiatimes.com/articleshow/1823674.cms

Migrating TB patients to be e-monitored
Anil Jerath, Tribune News Service, August 2, 2006

Phagwara (punjab): Tuberculosis patients who earlier used to do a vanishing act after availing medical treatment will now be e-monitored. Launching an ambitious project to keep tab on TB patients moving to other states, Punjab's Tuberculosis Centre has now been linked online to four states where patients are either referred out or transferred.

Talking to The Tribune, Dr R.L. Goyal, TB Officer, Punjab, said, "We were facing major problems in tracking patients who used to move out of the state after availing the direct observation treatment for TB. These patients showed their inability to continue the treatment here and went back to where they came from- mainly UP, Bihar, Himachal Pradesh and Haryana." Now the apathetic attitude of doctors monitoring TB in these states is likely to improve, hope Punjab health officials, since it has now become mandatory for the state TB officers to submit a report on such patients to the Central TB Division (CTD).

A website has been evolved by the CTD, which is linked to all four states to monitor this "migrating and travelling" population. "The main problem with TB patients is that the treatment requires long-term medication. A large number of patients default on this, making themselves vulnerable to developing multi-drug resistance," Dr Goyal added.
Source: http://www.tribuneindia.com/2006/20060803/jal.htm#6

Laser therapy hastens bacteria clearance in TB patients
Press Trust of India, January 31, 2006

Laser therapy added to the usual TB drugs has been found to hasten the bacteria clearance in patients, scientists claim, stating the therapy may help in shortening lengthy treatment, which drives several patients away from medication.

"The study has been carried out under the Department of Science and Technology at the LRS Institute of Tuberculosis and Respiratory Diseases," Dr M M Puri from the Department of TB and Respiratory Diseases at the hospital, who participated in the study, said. "We found that clearance of bacteria from sputum occurs significantly early in patients who are given drugs and laser therapy in comparison to those given only drugs," he said, adding that means these patients become non-infective faster.

The institute studied 60 patients in the study which is published in the Indian Journal of Chest Diseases. However, further studies are needed to find how much time reduction is possible, he said. There are plans to carry out a multicentric study under the Department of Science and Technology in which more patients would be studied, he said.

At a later date, laser therapy may become part of treatment, he said, adding the problem with TB is that patients need to take drugs for about six months. As the treatment is long, patients stop taking medicines after symptoms disappear. This increases the chance of drug resistance in patients who stop treatment, he said. The efforts in the scientific community are to reduce the treatment time, he said. Puri said an "external variation equipment is used to deliver laser to patients depending on the site of the disease. Two kinds of lasers - gallium arsenide lasers and helium neon lasers - are used for the purpose, he said. While drugs kill the bacteria, laser therapy stimulates the body's immune system to become more efficient, he said.
Full Story at: http://www.hindustantimes.com/news/181_1222421,00040007.htm

World Bank Supports India's Health Sector - $672 Million to Focus on Women, Children and Communicable Diseases
(24 Aug 2006)

The World Bank has approved a US$672 million package of assistance to India's health sector, designed to improve reproductive and child health services, reduce mortality and morbidity due to tuberculosis, and increase utilization of essential health services in the State of Karnataka. The three projects are the Reproductive and Child Health (RCH) II Project (US$360 million), the Second National Tuberculosis Control Project (US$170 million), and the Karnataka Health Systems Development and Reform Project (US$141.83 million).

The US$170 million credit for the Second National Tuberculosis Control Program aims to achieve the global targets of 70 percent case detection and 85 percent cure rate, and for the zones where Directly Observed Treatment Short course (DOTS) has been under implementation for five or more years, to decrease the incidence of smear-positive Tuberculosis (TB). While emphasis in the first phase of the program was on introducing DOTS in a uniform manner across the country, the program will now target the states which have below-average performance through additional technical and managerial support.

SAARC TB Activities: An Overview
Excerpts from an Editorial by Balaram Chaulagain in Gorkhapatra, Kathmandu (15 Aug, 2006)

TUBERCULOSIS (TB) continues to be one of the biggest killers, accounting for the death of around 40 percent people residing across SAARC region. Caused by bacillus named mycobacterium tuberculosis and mainly spread by droplet infection, TB has for decades challenged the health sector's endeavors to control it. Just a few decades ago, it seemed that TB could be checked through BCG vaccine. But time proved otherwise. When control measures could not be adequately sustained and proved less important, TB re-emerged as a major public health challenge of this time.

The problem is acute, particularly in the countries with low economic status. All countries in the SAARC region face a threat from Tuberculosis and growing incidence of drug resistant strains. Highly infectious type of pulmonary tuberculosis is considered to be the challenging threat to public health. Moreover, the growing trend of HIV/AIDS and its co-infection with TB is most dangerous from public health point of view.

While TB mortality is a cause for grave concern, equally great is the problem of TB morbidity. It debilitates communities and affects productivity. This situation allows no room for complacency. What is needed is stronger political will and commitment to embark on comprehensive control measures against this major public health menace. Unless this is done, TB will continue to extract a high toll in the years to come. As such, sectors, other than health, together with media, organized groups, communities, families and individuals have a critical role to play in this effort.

SAARC, which is a forum to end the problems faced by the people residing in the region, is on its way to maturity. Emphasis should be accorded high to make SAARC oriented towards controlling diseases and hunger in the region rather than stressing on theoretical aspects. As we approach a new millennium SAARC must reaffirm its commitment to support member countries and communities with the technology and the means to address these challenges. At a time when HIV/AIDS and TB both are raising their ugly heads more vigorously than ever before we need to strengthen partnerships. In this regard, India, the jumbo SAARC member can play a pivotal role to assimilate its counterparts into the regional partnership against TB and HIV/AIDS.

As TB is no longer the concern of governments or the health sectors alone, it is everyone's concern requiring a multi-sectoral effort. To achieve the laudable goal of controlling TB, mobilization of resources through mutual partnerships need to be tapped if effective TB control is to be achieved. TB is one of the most serious and contagious diseases of developing countries like ours.

As per a rough estimation around 2.5 million people of this region are supposed to be suffering from TB and around 1 million TB deaths occur each year in SAARC countries. It is obvious that as long as we fail to adopt DOTS strategy in combating TB we can't achieve success. Reports received from SAARC TB centre enlist series of TB and HIV curbing measures are being carried out by the Center located in the capital city of Nepal. Let us hope in the days to come SAARC level sound TB activities will also be launched as per the need of time.
Read the full text at: http://www.gorkhapatra.org.np/content.php?nid=1276

WHO updates aviation guidelines for TB prevention

WHO has issued updated guidelines for the airline industry that will further minimise the risk of tuberculosis (TB) and other infectious diseases being passed from passenger to passenger on board aircraft. The 'Tuberculosis and Air Travel' guidelines stipulate that people with infectious TB must postpone long-distance travel, while those with multidrug-resistant tuberculosis (MDR-TB) must postpone any air travel.

To date, no case of active TB has been identified as a result of exposure on a commercial aircraft. The quality of the air on board commercial aircraft is high and under normal conditions cabin air is cleaner than the air in most buildings. Prolonged journeys of more than eight hours in a confined aircraft cabin may involve an increased risk of transmission, but the risk should be similar to that in other circumstances where people are together in other confined spaces.

The guidelines also advise that aircraft ventilation systems should continue to operate when the aircraft is delayed on the ground and the doors are closed. If not in operation, ground delays should be kept to less than 30 minutes. The International Air Transport Association (IATA) and its partners, including WHO, are actively looking at ways to improve the accuracy and availability of passenger information. As an interim measure, a locator card has been developed. If there is a suspected case of a communicable disease of international importance on board, designated passengers would be asked fill it out. The card records the name, seat number and emergency contact information.
Download the guidelines [pdf 728kb] at: http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.363_eng.pdf
----------------------------------------------------------------------------------Editorial Team:
Dr. Dinesh Kumar Sharma, dineshkumarsharma@gmail.com
Dr. Jatinder Singh, jatindersingh@vsnl.com
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